Medical Treatment Authorization form when traveling

[Guest guest]

Since it has been a while.I thought I would send this for anyone who has to

leave a child with caregivers for a few days or whatever... this is

something we have used for our oldest son in the past. When I first wrote

this, it took me a while to come up with it! LOL Feel free to copy it and

pass it along to others who could use it.

Medical Treatment Authorization

Date

To whom it may concern:

_________ and ___________ will be caring for our child,___________, from

_____through ______

We hereby authorize and voluntarily consent to having ________ and

__________arrange, direct, sign for and consent to any and all routine or

emergency medical care and treatment necessary to preserve the health of our

child. Personal, insurance and health care provider information is set

forth below.

We acknowledge that we are responsible for all reasonable charges in

connection with the care and treatment rendered.

Child's Personal information:

Name:

Date of Birth:

Allergies: no known allergies to food or medication

Medical Conditions: no known medical conditions

Insurance Information:

Insurance Company:

Insured:

Employer:

Subscriber ID:

Group Number:

Co-Pays:

A copy of the insurance card is attached to this letter.

Pediatrician: name and number

_________________________________

_______________________________

XXXXXXXXXXXX, Father XXXXXXXXX , Mother

Peace be with you,

Pattie

Look what God is doing with nothing. People must believe that it is all his,

all his. We must allow God to use us, without adding or subtracting

anything. ~ Bl. Mother of Calcutta

www.catholicmomof3.blogspot.com